Observations
Based on a review of client records on August 15, 2023, the facility failed to document the frequency of services in the treatment plan in two of five client records.
Client #2 was admitted on 5/9/23 and was a current client at the time of the investigation. The master treatment plan dated 5/16/23 and the treatment plan update dated 7/7/23 were both missing the frequency of services.
Client #3 was admitted on 10/13/2022 and discharged on 3/28/2023. The master treatment plan dated 10/14/22 and the treatment plan updates dated 11/14/22, 12/14/22, 1/9/23, 2/20/23, and 3/7/23 were all missing the frequency of services.
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Plan of Correction
The clinical Director will review and audit individual treatment plans weekly; to ensure that scopes of services services are met as well as make sure The treatment plans states the type, amount, frequency, and duration of the services to be furnished and
indicate the diagnoses and anticipated goal. this plan was discussed in treatment team and implemented effectively August 23, 2023. |